Importance of Submitting Complete Encounter Data

As you know, CMS now uses a combination of RAPS (Risk Adjustment Processing System) data and encounter data submitted thru EDPS (Encounter Data Processing System) as inputs into the payment system for projecting RAFs (Risk Adjustment Factors), which is a key input to payment model for MAPD (Medicare Advantage Prescription Drug) health plans.  CMS requires that all encounter data be submitted by MAPD health plans, including services not covered by CMS in Fee-For-Service (FFS) Medicare.

Due to the growth of payment strategies such as capitation in MAPD, providers are no longer financially incentivized to provide complete data as they were in the traditional claims billing process.  This has been a widely identified trend in MAPD professional data, but also occurs in the inpatient setting which often contains more robust information then other places of service.  Missing encounter data and the growth of the gap in these data (between MAPD and FFS) has a number of important ramifications for MAPD:

• ·        It causes inaccuracies in payment because treated conditions are not reported and therefore not loaded into the payment model
• ·        It suggests a distorted picture of members’ true disease burden as being lower than the actual
• ·        It suggests incorrectly to CMS that MAPD members are receiving fewer services than beneficiaries in traditional Medicare (FFS)

Some possible drivers for this under-reporting are:

• ·        Failure to submit data from sub-capitated providers, including hospitals
• ·        The purposeful filtering of encounter data submitted to the plan with the goal of providing only incremental HCC model data
• ·        Downstream data that medical groups processes as claims are not always extracted and reported. This is especially true when the groups’ encounter data and claims data are on different platforms.
• ·        Selective reporting from providers of only risk adjustable diagnoses in MAPD and only providing a single E&M procedure code so that the encounter will process
• ·        Submitting reporting from providers of only diagnoses “linked” to a procedure code for traditional Medicare claims or only the minimum needed for the claim to process

While there are no mechanisms in traditional Medicare at present to submit additional diagnosis data (maximums are currently <=8 diagnoses for professional, <=25 diagnoses for institutional), it’s important to submit all documented diagnoses and procedures for both programs.  In traditional Medicare where there are more diagnoses then 8, we would suggest that the provider or biller first choose linked diagnoses followed by the diagnoses that most accurately reflect the need for the visit and evaluations conducted at that service.  Similarly, reporting all CPT/HCPCS codes is important since it is the only way that CMS can gain an accurate picture of procedures performed with the goal of trying to understand and compare value between the programs. 

At present we believe that there are a number of systematic biases that are impacting the accuracy of the view CMS has on the health status of the entire Medicare population, biasing towards fewer CPT/HCPCS for MAPD and fewer ICD codes for traditional FFS.

NOTE:

Remember, SCAN’s Encounter and Risk Adjustment provider team is here to assist you.  Please reach out to Michelle Nguyen at MNguyen3@scanhealthplan.com for assistance.

An Important Message From Our Encounter Data Team About the January and March Sweeps

Hello SCAN Provider Partners,

The January CMS Encounter Data Sweep is approaching. We are 4 weeks away from SCAN’s Target Date! This is the FINAL CMS sweep impacting 2016 DOS (2017 payment) and requires the submission of encounters for DOS range 01/01/2016 à12/31/2016. CMS currently plans a 75% RAPS and Fee for Service and 25% EDS and Fee for Service blended risk score based on 2016 DOS.

Additionally, we are now 8 weeks away from SCAN’s Target Date for the March CMS Encounter Data Sweep, which requires the submission of encounters for DOS range 01/01/2017 à12/31/2017. CMS currently plans a 85% RAPS and Fee for Service and 15% EDS and Fee for Service blended risk score based on 2017 DOS.

SCAN has two dates for you to manage towards for the January 2018 sweep:

Ø  SCAN Target Date for Provider Partners: EOB Friday, December 29, 2017

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  SCAN Deadline for Provider Partners: EOB Friday, January 26, 2018

o   After this deadline, SCAN will NOT process any files received for the January CMS sweep

SCAN has two dates for you to manage towards for the March 2018 sweep:

Ø  SCAN Target Date for Provider Partners: EOB Friday, January 26, 2018

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  SCAN Deadline for Provider Partners: EOB Friday, February 23, 2018

o   After this deadline, SCAN will NOT process any files received for the March CMS sweep

7 STEPS YOU CAN TAKE TO PREPARE:

1. Review your SCAN monthly Encounter Submission Reports
1. November reports were uploaded to the SCAN Encounter Data Portal on 12/01/2017. The next ESRs will be uploaded the first week of January 2018.

2.       Review your SCAN Encounter HCC Reconciliation Reports

1. This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

  

3. Review your SCAN All DX Reconciliation reports
1. This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

§ QUESTION: What is the All Diagnoses (DX) Reconciliation report?

§ ANSWER: A report containing all diagnosis codes received from your group for dates of service 01/01/2016 à 12/31/2016 or 01/01/2017 à 12/31/2017.

2. This report can be leveraged along with the HCC Reconciliation report to match up to your database and ensure all of your encounter data has been sent to SCAN.

4. Review your SCAN PCN Reconciliation reports
1. This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

§  QUESTION: What is the Patient Control Number (PCN) Reconciliation report?

§  ANSWER: A report containing a list of all the PCNs received from your group for dates of service 01/01/2016 à 12/31/2016 or 01/01/2017 à 12/31/2017. The PCN field provides you with the ID received from you for each encounter (a.k.a. claim ID). You may reconcile the list of PCNs against your system to ensure that SCAN has received all of your PCNs. If any are missing on our list that exist in your system, then you can identify those as needing to be submitted to SCAN immediately

2. If you are already reconciling against the PCN report, then continue to do so and provide an update on results as soon as available.

*The above reports are designed to help you ensure that all possible encounter data for SCAN members has been sent to SCAN to meet the CMS health plan cut-off date of January 31, 2018 for the January Sweep and March 2, 2018 for the March Sweep.

Additional Steps:

5. Work your clearinghouse rejections via OfficeAlly, Ability Network, or Change Healthcare

6. Upload all ICE alternative submission files to SCAN via the Encounter Data Portal (providerportal.scanhealthplan.com) using the File Transmission link
1. It is your responsibility to ensure that the file uploaded is processed successfully. Due to the larger number of files received during sweep timeframes, it becomes very difficult to provide 1:1 attention on these files. Please refer to the SCAN ICE file specifications located on the SCAN Encounter Data portal or you may email me to request the documents to ensure the success of your file upload.
2. Send these files sooner than later; please do not to wait until December 29, 2017 to upload your 2016 DOS files for the January Sweep. Additionally, please do not wait until January 26^th to upload your 2017 DOS files for the March Sweep.
3. ICE files should only be used to submit additional DX codes or deletes of DX codes.

§ SCAN expects to receive all original encounter data records via your normal clearinghouse workflow.

7. Follow up on additional cleanup requests (contact your respective HCI representative with your direct questions)
1. Provider Name Mismatch (PNM) rejection reports
2. Rendering Provider/Entity (RPX) rejection reports
3. EDS Full Encounter Data rejection reports
4. Invalid DX rejection reports
5. ICE File Pend reports

What are the Timelines?

1. Submit all 01/01/2016 à 12/31/2016 DOS encounters to your Clearinghouse: 12/29/2017
2. Last day for ICE file submissions of additions/deletions of DX codes for 01/01/2016 à 12/31/2016 to SCAN: 12/29/2017
3. January CMS Sweep deadline for SCAN: 01/31/2018
4. Submit all 01/01/2017 à 12/31/2017 DOS encounters to your Clearinghouse: 01/26/2018
5. Last day for ICE file submissions of additions/deletions of DX codes for 01/01/2017 à 12/31/2017 to SCAN: 02/23/2018
6. March CMS Sweep deadline for SCAN: 03/02/2018

* Remember: SCAN has two dates for provider partners to manage towards for the January and March Sweep:

Ø  January Sweep SCAN Target Date for Provider Partners: EOB Friday, December 29, 2017

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  January Sweep SCAN Deadline for Provider Partners: EOB Friday, January 26, 2018

o   After this deadline, SCAN will NOT process any files received for the January CMS sweep

Ø  March Sweep SCAN Target Date for Provider Partners: EOB Friday, January 26, 2018

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  March Sweep SCAN Deadline for Provider Partners: EOB Friday, February 23, 2018

o   After this deadline, SCAN will NOT process any files received for the March CMS sweep

Please be prepared for continued communication from SCAN. We look forward to supporting and working with you during this upcoming sweep period!

  

If you have any questions or concerns, please feel free to contact me directly or reach out to SCAN’s HCI Representative:

o   Michelle Nguyen: MNguyen3@scanhealthplan.com

Best regards,

Christina Cabiltes

Supervisor, HCI Projects

A Special Message From Our Encounter Data Team About Data Submission

Hello SCAN Provider Partners,

The January CMS Encounter Data Sweep is approaching. We are 5 weeks away from SCAN’s Target Date! This is the FINAL CMS sweep impacting 2016 DOS (2017 payment) and requires the submission of encounters for DOS range 01/01/2016 à 12/31/2016. CMS currently plans a 75% RAPS and Fee for Service and 25% EDS and Fee for Service blended risk score based on 2016 DOS.

SCAN has two dates for you to manage towards:

Ø  SCAN Target Date for Provider Partners: EOB Friday, December 29, 2017

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  SCAN Deadline for Provider Partners: EOB Friday, January 26, 2018

o   After this deadline, SCAN will NOT process any files received for the January CMS sweep

7 STEPS YOU CAN TAKE TO PREPARE:

1. Review your SCAN monthly Encounter Submission Reports
1. November reports were uploaded to the SCAN Encounter Data Portal on 11/01/2017. The next ESRs will be uploaded the first week of December 2017.

2.       Review your SCAN Encounter HCC Reconciliation Reports

1. This report is available to you monthly. If you would like to utilize this report for the January Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

b.      Reports with dates specific to the January CMS sweep dates 01/01/2016 à 12/31/2016 will be uploaded before end of week 11/13/17.

  

3. Review your SCAN All DX Reconciliation reports
1. This report is available to you monthly. If you would like to utilize this report for the January Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

§ QUESTION: What is the All Diagnoses (DX) Reconciliation report?

§ ANSWER: A report containing all diagnosis codes received from your group for dates of service 01/01/2016 à 12/31/2016.

2. This report can be leveraged along with the HCC Reconciliation report to match up to your database and ensure all of your encounter data has been sent to SCAN.

4. Review your SCAN PCN Reconciliation reports
1. This report is available to you monthly. If you would like to utilize this report for the January Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

§  QUESTION: What is the Patient Control Number (PCN) Reconciliation report?

§  ANSWER: A report containing a list of all the PCNs received from your group for dates of service 01/01/2016 à 12/31/2016. The PCN field provides you with the ID received from you for each encounter (a.k.a. claim ID). You may reconcile the list of PCNs against your system to ensure that SCAN has received all of your PCNs. If any are missing on our list that exist in your system, then you can identify those as needing to be submitted to SCAN immediately

2. If you are already reconciling against the PCN report, then continue to do so and provide an update on results as soon as available.

*The above reports are designed to help you ensure that all possible encounter data for SCAN members has been sent to SCAN to meet the CMS health plan cut-off date of January 31, 2018.

Additional Steps:

5. Work your clearinghouse rejections via OfficeAlly, Ability Network, or Change Healthcare

6. Upload all ICE alternative submission files to SCAN via the Encounter Data Portal (providerportal.scanhealthplan.com) using the File Transmission link
1. It is your responsibility to ensure that the file uploaded is processed successfully. Due to the larger number of files received during sweep timeframes, it becomes very difficult to provide 1:1 attention on these files. Please refer to the SCAN ICE file specifications located on the SCAN Encounter Data portal or you may email me to request the documents to ensure the success of your file upload.
2. Send these files sooner than later; please do not to wait until December 29, 2017 to upload your files.
3. ICE files should only be used to submit additional DX codes or deletes of DX codes.

§ SCAN expects to receive all original encounter data records via your normal clearinghouse workflow.

7. Follow up on additional cleanup requests (contact your respective HCI representative with your direct questions)
1. Provider Name Mismatch (PNM) rejection reports
2. Rendering Provider/Entity (RPX) rejection reports
3. EDS Full Encounter Data rejection reports
4. Invalid DX rejection reports
5. ICE File Pend reports

What are the Timelines?

1. Submit all 01/01/2016 à 12/31/2016 DOS encounters to your Clearinghouse: 12/29/2017
2. Last day for ICE file submissions of additions/deletions of DX codes for 01/01/2016 à 12/31/2016 to SCAN: 12/29/2017
3. CMS Sweep deadline for SCAN: 01/31/2018

* Remember: SCAN has two dates for provider partners to manage towards:

Ø  SCAN Target Date for Provider Partners: EOB Friday, December 29, 2017

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  SCAN Deadline for Provider Partners: EOB Friday, January 26, 2018

o   After this deadline, SCAN will NOT process any files received for the January CMS sweep

Please be prepared for continued communication from SCAN. We look forward to supporting and working with you during this upcoming sweep period!

  

If you have any questions or concerns, please feel free to contact me directly or reach out to SCAN’s HCI Representative:

o   Michelle Nguyen: MNguyen3@scanhealthplan.com

Best regards,

Christina Cabiltes

Supervisor, HCI Projects

*IMPORTANT* -- SCAN Dates for Upcoming September 2017 Encounter Data CMS Sweep

Special Notice to SCAN Providers

Hello SCAN Provider Partners,

The September CMS Encounter Data Sweep is approaching. We are 4 weeks away from SCAN’s Target Date! This is the INITIAL CMS sweep impacting 2017 DOS (2018 payment) and requires the submission of encounters for DOS range:

• 07/01/2016 à 06/30/2017

SCAN has two dates for you to manage towards:

Ø  SCAN Target Date for Provider Partners: EOB Friday, August 11, 2017

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  SCAN Deadline for Provider Partners: EOB Friday, September 1, 2017

o   After this deadline, SCAN will NOT process any files received for the September CMS sweep

7 STEPS YOU CAN TAKE TO PREPARE:

1. Review your SCAN monthly Encounter Submission Reports
1. June reports were uploaded to the SCAN Encounter Data Portal on 06/13/2017. The next ESRs will be uploaded the first week of July 2017.

2.       Review your SCAN Encounter HCC Reconciliation Reports

1. This report is available to you monthly. If you would like to utilize this report for the September Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

b.      Reports with dates specific to the September CMS sweep dates 07/01/2016 à 06/30/2017 will be uploaded before end of week 07/14/17.

  

3. Review your SCAN All DX Reconciliation Reports
1. This report is available to you monthly. If you would like to utilize this report for the September Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

§ QUESTION: What is the All Diagnoses (DX) Reconciliation report?

§ ANSWER: A report containing all diagnosis codes received from your group for dates of service 07/01/2016 à 06/30/2017.

2. This report can be leveraged along with the HCC Reconciliation report to match up to your database and ensure all of your encounter data has been sent to SCAN.

4. Review your SCAN PCN Reconciliation Reports
1. This report is available to you monthly. If you would like to utilize this report for the September Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

§  QUESTION: What is the Patient Control Number (PCN) Reconciliation report?

§  ANSWER: A report containing a list of all the PCNs received from your group for dates of service 07/01/2016 à 06/30/2017. The PCN field provides you with the ID received from you for each encounter (a.k.a. claim ID). You may reconcile the list of PCNs against your system to ensure that SCAN has received all of your PCNs. If any are missing on our list that exist in your system, then you can identify those as needing to be submitted to SCAN immediately

2. If you are already reconciling against the PCN report, then continue to do so and provide an update on results as soon as available.

*The above reports are designed to help you ensure that all possible encounter data for SCAN members has been sent to SCAN to meet the CMS health plan cut-off date of September 8, 2017.

Additional Steps:

5. Work your clearinghouse rejections via OfficeAlly, Ability Network, or Change Healthcare

6. Upload all ICE alternative submission files to SCAN via the Encounter Data Portal (providerportal.scanhealthplan.com) using the File Transmission link
1. It is your responsibility to ensure that the file uploaded is processed successfully. Due to the larger number of files received during sweep timeframes, it becomes very difficult to provide 1:1 attention on these files. Please refer to the SCAN ICE file specifications located on the SCAN Encounter Data portal or you may email me to request the documents to ensure the success of your file upload.
2. Send these files sooner than later; please do not to wait until September 1, 2017 to upload your files.
3. ICE files should only be used to submit additional DX codes or deletes of DX codes.

§ SCAN expects to receive all original encounter data records via your normal clearinghouse workflow.

7. Follow up on additional cleanup requests (contact your respective encounter data representative with your direct questions)
1. Provider Name Mismatch (PNM) rejection reports
2. Rendering Provider/Entity (RPX) rejection reports
3. EDS Full Encounter Data rejection reports

What are the Timelines?

1. Submit all 07/01/2016 à 06/30/2017 DOS encounters to your Clearinghouse: 08/11/2017
2. Last day for ICE file submissions of additions/deletions of DX codes for 07/01/2016 à 06/30/2017 to SCAN: 08/11/2017
3. CMS Sweep deadline for SCAN: 09/08/2017

* Remember: SCAN has two dates for provider partners to manage towards:

Ø  SCAN Target Date for Provider Partners: EOB Friday, August 11, 2017

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  SCAN Deadline for Provider Partners: EOB Friday, September 1, 2017

o   After this deadline, SCAN will NOT process any files received for the September CMS sweep

Please be prepared for continued communication from SCAN. We look forward to supporting and working with you during this upcoming sweep period!

  

If you have any questions or concerns, please feel free to contact me directly or reach out to SCAN’s Encounter Data Specialist:

o   Steve Vo: svo@scanhealthplan.com

Best regards,

Christina Cabiltes

Supervisor, HCI Projects

CCabiltes@scanhealthplan.com

Encounter Data Filtering Logic Updates

As you probably know, CMS has provided guidance regarding the filtering of encounter data for risk adjustment purposes.  This doesn't mean that either Medical Groups or Health Plans should not submit certain encounters- CMS requires that ALL encounter data must be submitted to them.

Currently, encounter data represents 25% of the calculation of risk scores.  CMS plans to increase the weighting of encounter data-based risk scores over the next couple of years by moving to a risk score incorporating 50% of the encounter data/FFS-based risk score in 2018, a risk score incorporating 75% of the encounter data/FFS-based risk score for 2019, and a risk score of 100% encounter data/FFS-based risk score in 2020,

The logic that they use to determine what encounters are included is laid out in this 2015 memo from CMS to health plans.  At the same time, CMS released a list of procedure codes that would be used for filtering professional and outpatient hospital encounters.  

Recently, CMS released the list of 2015 codes and preliminary 2016 codes to be used for encounter data filtering.

When determining which encounters may be used in calculating risk scores, health plans and provider groups should refer to these documents, as well as reports received from CMS and health plans.  As CMS moves forward with using only encounter data for risk score calculation it will become more important than ever that your encounter data be accepted by the health plan and ultimately by CMS.  We will continue to provide you as much information as possible on our Encounter Data/ICD-10 Page.  CMS is currently hosting teleconferences with health plans, to keep them informed about changes to encounter data processing.  We'll post webinar slides like these, on duplicate record and demographic data fields processing, so you can stay up to date as well.

What other tools would be helpful to you?  Remember, if you have suggestions for HCC University, or the blog, you can contact us at coding@scanhealthplan.com.

Updated "Ask a Coder" questions on HCC University!

We've added 9 new questions, most about ICD-10, to the Ask a Coder section on HCCUniversity.com.  In addition, most of the older questions have been updated to include ICD-10 information.

On the Full Encounter Data/ICD-10 page, we've added an updated CMS Encounter Data Processing System (EDPS) Newsletter, which reminds physicians and DME suppliers that ICD-9 and ICD-10 cannot be billed on the same claim/encounter.  If there are services both prior to and on or after 10-1-15, you must split them and put them on separate claims.

For hospitals, the discharge date determines which coding system applies to the whole claim.  So, if a patient is admitted on 9-20-15, and discharged on 10-1-15, all services will be billed under the ICD-10 coding system.

Finally, remember you can ask risk adjustment related coding questions by submitting an email to coding@scanhealthplan.com.

Stay tuned for more exciting news from HCCUniversity.com!

SCAN Memo On Encounter Data Submission Deadlines

The SCAN Encounter Data Team has published the memo below, and sent it to all Encounter Data contacts.  We're reprinting the content here, to enable you to better support your Encounter Data staff in timely submissions.  As noted below, if you have questions regarding this memo, please email them to Encounters_Operation@scanhealthplan.com with the subject line ‘SCAN Dates for Submission of Risk Adjustment Data to CMS’.

______________________________________________________________________

To: All SCAN Provider Partners, including Groups, Hospitals and Ancillary Providers
CC: SCAN Encounter Data Team
From: SCAN Health Plan
Date: 7/2/2015
Re: *IMPORTANT* -- SCAN Dates for Submission of Risk Adjustment Data to CMS
Below are SCAN dates for the next five CMS Sweeps for risk adjustment data. Please note, in addition to the CMS deadline for Health Plans, SCAN has created two key submission dates for our Provider Partners: 1) SCAN Target Date and 2) SCAN Deadline.
SCAN Target Date
The “SCAN Target Date” (yellow in the below matrix) is the date after which any new data received is subjected to increased scrutiny and is at some risk of not being processed with CMS for that sweep. This date is approximately 4 weeks prior to each of the CMS deadlines, and has been set to ensure that SCAN has adequate time to complete processing prior to the cut-off by CMS. Again, any data received after this date will be subject to additional scrutiny which may include (but is not limited to) successfully passing a random chart validation. After the additional scrutiny is concluded, the data will be submitted to CMS but SCAN cannot guarantee that this will occur prior to the CMS deadline for Health Plans.
Note: If your organization uses a clearinghouse, all encounter data should be received by the clearinghouse well before the SCAN Target Date to ensure CMS processing. Any files that are submitted directly to SCAN (i.e. ICE files), must also be received by the SCAN Target Date.
SCAN Deadline
The “SCAN Deadline” (red in the below matrix) is the date after which any data received will NOT be processed for that sweep. This is an important change that SCAN is making for each CMS sweep period. This will be the final date SCAN will receive any data that may be sent to CMS prior to the Sweep Deadline for Health Plans.
Note: While the SCAN Deadline is the critical date for each sweep, it is especially so for the final CMS sweeps (highlighted in blue in the below matrix) for any given calendar year. Please mark your calendars now for 1/22/2016, the next SCAN Deadline prior to a final sweep!